Wrong Site Surgeries
There is right. And there is left.
It is as simple as that.
One would think that before operating on a patient's brain a surgeon would know what side of the brain needed work. And that at least one of the nurse's or techs in the operating room would know.
But this article from the Boston Globe tells us that a hospital in Rhode Island has had three wrong side brain surgeries this year. And the year is not over.
One news report indicates that wrong site surgery occures between 1300 and 2700 times per year in the United States.
The Joint Commission has addressed this issue:
"In July 2003, The Joint Commission Board of Commissioners approved the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery™. The Universal Protocol was created to address the continuing occurrence of these tragic medical errors in Joint Commission accredited organizations. The Universal Protocol became effective July 1, 2004 for all accredited hospitals, ambulatory care and office-based surgery facilities. The Universal Protocol drew upon, and expanded and integrated, a series of requirements under The Joint Commission’s 2003 and 2004 National Patient Safety Goals. It is applicable to all operative and other invasive procedures. The principal components of the Universal Protocol include: 1) the pre-operative verification process; 2) marking of the operative site; 3) taking a ‘time out’ immediately before starting the procedure; and 4) adaptation of the requirements to non-operating room settings, including bedside procedures. The protocol is endorsed by 51 professional health care associations and organizations. . . ."
Here is a copy of the Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery ™
An article in the Archives of Surgery concluded that "[w]rong-site surgery is unacceptable but exceedingly rare, and major injury from wrong-site surgery is even rarer. Current site-verification protocols [which include the universal protocol] could have prevented only two thirds of the examined cases. Many protocols involve considerable complexity without clear added benefit." That study found the rate of wrong site surgery to be 1 in 112,994 operations.
Two brief thoughts. First, let's find a way to follow the Universal Protocol to prevent two-thirds of the injuries. Then, let's find a way for doctors and OR personnel to know the name and diagnosis of each patient they are operating on.
That should work.